Social and Cultural Aspects of Drug Abuse in Adolescents

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1 Review Article Social and Cultural Aspects of Drug Abuse in Adolescents R.C. Jiloha Department of Psychiatry, MAMC & GB Pant Hospital, New Delhi Almost all cultures have used psycho-active drugs to facilitate social interaction, to alter consciousness, to heal. Our society s expanded chemical manipulation simply represents a large technical capacity, more wealth, leisure, individual choice and, conversely, a reduction in constraining social settings, peer and family standards, and personal proscriptions as to what is not done. 1 Drugabuse behaviour like human behaviour in general is conceived of as an outcome of genetic and biochemical characteristics, past lear ning experiences, motivational states, psychosocial antecedents, and cultural context in which it unfolds. These conditions assume a considerable variety in drug-abuse behaviour. Among these, social and cultural factors play an important role in initiation, maintenance and therapeutic intervention of drug-abuse. Social norms, the shared rules, that specify appropriate and inappropriate behaviours; mores, that people consider vital to their well-being and to their most cherished values and sanctions, the socially imposed rewards and punishments that compel people to comply with norms, constitute important ingredients of a culture. Culture is defined as shared values, beliefs, norms, traditions, customs art, history, folklore and institutions of a group of people. No single or generic set of variables explains the misuse of substances for every individual. Depending on an individual s biological makeup, developmental stage, and interaction with various environmental forces, individual risk, vulnerability, and resilience to substance abuse and addiction will vary for different factors at different times 2. Indian society, which enjoys cultural diversity, has a history of use of plant products, viz., cannabis, opium, and home brewed alcohol beverages within a defined socio-cultural framework over five millennium. There are certain social groups which are more vulnerable to substance abuse. Caste, religion and local customs and traditions play significant role in the choice of drugs, their consumption and their control in rural/semi-urban populations. Though some workers describe Indian society to be traditionally abstinent, the recent developments do not support this concept. In India the numbers of drug addicts are increasing day by day. India also has a huge at-risk young population with 40% being below the age of 18 years. According to UN Convention Reports on Narcotic Drugs and Psychotropic Substances in 1961, 1971 and 1988, it is estimated that, in India, by the time most boys reach the ninth grade, about 50% of them have tried at least one of the gateway drugs. A larger proportion of teens in West Bengal and Andhra Pradesh have been using gateway drugs (about 60% in both the states) than Uttar Pradesh or Haryana (around 35%). Smokeless tobacco in the form of gutka is commonly used by children and adolescents in certain states. Every year, about 55,000 children take up to smoking generally hailing from low socio-economic strata with poor social support, broken homes and victims of deprivation and discrimination. This risky behavior is often initiated during childhood and adolescence, as more than 70% of adult smokers report that they started smoking on a daily basis prior to age One million heroin addicts are registered in India, and unofficially there are as many as five million. Cannabis, heroin, and Indian-produced pharmaceutical drugs are the most frequently abused drugs in India. Cannabis products, such as charas, bhang, or ganja, are abused throughout the country because of religious sanctity and its association with some Hindu deities. The International Narcotics Control Board in its 2002 Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 167

2 DELHI PSYCHIATRY JOURNAL Vol. 12 No.2 OCTOBER 2009 report released in Vienna pointed out that in India persons addicted to opiates are shifting their drug of choice from opium to heroin. The pharmaceutical products containing narcotic drugs are also increasingly being abused. The intravenous injections of analgesics like dextropropoxphene etc are reported from many states, as it is easily available at 1/10th the cost of heroin. The codeinebased cough syrups continue to be diverted from the domestic market for abuse. Drug abuse is a complex phenomenon, which has various social, cultural, biological, geographical, historical and economic aspects. The disintegration of the old joint family system, absence of parental love and care in modern families where both parents are working, decline of old religious and moral values etc lead to a rise in the number of adolescent drug addicts who take drugs to escape hard realities of life. The processes of industrialization, urbanization and migration have led to loosening of the traditional methods of social control rendering an individual vulnerable to the stresses and strains of modern life. The fast changing social milieu, among other factors, is mainly contributing to the proliferation of drug abuse, both of traditional and of new psychoactive substances. The introduction of synthetic drugs and intravenous drug use leading to HIV/AIDS has added a new dimension to the problem, especially in the Northeast states of the country. Drug use, misuse or abuse is also primarily due to the nature of the drug abused, the personality of the individual and the addict s immediate environment. Kastner and Silbereisen 4 demonstrated that drug abuse among adolescents is clearly related to the developmental pressures. They ascertained that the use of drugs can assume developmental relevance in 6 ways: 1. A deliberate vilation of social norms 2. Testing whether the adolescent is able to behave like an adult. 3. Excessive and ritualized behaviour in the sense of testing one s limits. 4. A lack of self control and thus an indicator of underdevelopment. 5. An age related life-style, aimed at peergroup integration. 6. An emergency reaction to age-related every day stress, thus a developmentally relevant coping strategy. Social and Cultural Factors Associated with Drug Abuse in Adolescents There are many factors that play a part in initiation and maintenance of drug abuse in adolescents. Initiation of drug use is complex 3 with multiple factors contributing in the onset of this behaviour. The social and cultural factors influencing the initiation of tobacco use vary from country to country, from developed world to developing nations, region to region and culture to culture. 1. Parental Influence Parents have a tremendous influence on their children and the children of smoker parents are twice likely to become smokers 5 Parental disapproval of smoking makes an adolescent less likely to initiate smoking. 6 Female adolescents are more likely to be smokers if both parents are smokers. There is a strong correlation between mother smoking and the female youth becoming a smoker. 7 Raised in a home where parents smoke exposes the young person to tobacco smoke. Parents who smoke may also give easy access to cigarettes and less likely to oppose their children s smoking. The children are also more likely to smoke whose elder siblings are smokers 8. Cannabis, a traditional drug in Indian society is ritualized in social and religious gatherings. It is a socially sanctioned behaviour in certain cultural groups to use Bhang and Charas by adolescents and has parental approval for that. Parental attitude towards alcohol plays an important role in initiating the adolescent to drink alcohol. 2. Family Structure Higher levels of parental education and socioeconomic variables have inverse relationship with tobacco use and use of other psycho-active substances among adolescents. 9 Prevalence of smoking is more common in families which are with low socio-economic educational status of the society. Children using inhalants generally hail from low socio-economic status, engaged in menial work with unstable family income. Marital discord, divorce among parents, single parenting, are associated with drug abuse among adolescents. Parents having poor monitoring of their children are likely to have their children abusing drugs. 168 Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society

3 3. Peer Influence Friends have the greatest influence on the young smokers. The initiation of tobacco smoker generally occurs in the company of a friend who is a smoker. 10 Female adolescents with a best friend who is a smoker are nine times more at risk to become smokers. Smoking is a shared activity with important socializing functions for female youth. 11 Peer smoking also predicts continued smoking among young people who have already begun to smoke. 12 Cannabis abuse in school-going population has been associated with poor scholastic performance, school dropout and reinforcement of conduct symptoms These adolescents form their own peer group. 4. Role Model Film and TV stars, pop stars and fashion models make smoking seem attractive 13 and the adolescents imitate them to smoke their style. They leave tremendous impact on adolescent mind. 5. Advertising and Promotion Advertising is an effective weapon to influence the decision of young to initiate smoking. Advertising bans have been found to be very effective in reducing cigarette smoking prevalence in youth. 14. Indian Government has banned advertisement of cigarettes and other tobacco products through an Act Socio-economic Factors Higher drug-abuse rates are observed in lower income groups. Adolescents from low socioeconomic background are more likely to become smokers than the middle-class counterparts. This difference in smoking pattern may reflect divergent beliefs about tobacco use based on socio-economic status. 16 In India, beedi smoking is more common in adolescents for the reasons of easy availability, low in price and convenient to use. Adolescents from low income families tend to use cheap and spurious country-made liquor prepared illegally. Use of inhalants is also common in the adolescents from poor families. 7. Availability Availability and accessibility are important factors in initiation and maintenance of drug abuse among adolescents. An adolescent who has an easy access to drugs or alcohol because his parents or elder sibling is using, is more likely to use these drugs than those whose parents or any one else is not using these in the family. Similarly peer group members making the product available are likely to r ecruit new adolescents in the drug use behaviour Knowledge, Attitude and Beliefs Knowledge about the detrimental health effects has preventive effect on drug use. Some believe that moderate alcohol consumption does not have adverse effects, tobacco cessation could lead to weight gain and cannabis is a social and religious blessing of gods. These beliefs permit the adolescents to use drugs without hesitation or guilt. Positive attitude towards the drugs is likely to initiate drug use among the adolescents. Street Children and Drug Abuse According to UNICEF 18, 100 million children live and work on the streets of the cities of the world: 40 million in Latin America, million in Asia, and 10 million in Africa. India has the largest number of street children in the world. Though, India is largely still rural, urbanization is taking place rapidly, leading to fast growth of slums and shanty towns. All these factors have resulted in an explosion of street children in the country. 18 million children lived and worked in India s slums qualifying to be the street children 19. According to WHO estimates, up to 90% of the world s street children abuse some kind of drugs. There is no systematic data on the prevalence of drug abuse in street children in India and the published literature is available from the metropolitan cities only. The National Household Survey on Drug Abuse 20 surveyed 40,697 males of whom 8,587 were children (aged years). Of these, 3.8% were using Alcohol, 0.6% Cannabis and 0.2% opiates. Though this survey looked into the substance use pattern of children living in houses it provided a yardstick for comparing the substance use in street children. Those who reported for treatment of substance use in the treatment centres, patients below 20 years of age constituted 5% of all patients. However, more than 70% of all patients Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 169

4 DELHI PSYCHIATRY JOURNAL Vol. 12 No.2 OCTOBER 2009 initiated their drug abuse before 20 years of age. It means that most of the drug users start early in their adolescence but remain hidden from intervention services. Socio-demographic profile: In a Bangalore study of 281 children, 197 were found to be using drugs. The mean age of children using drugs was 13.3 years (range years). Other studies too found only the boys among street children using drugs. Most of these children are school drop-outs (90%). Majority of these children worked as unskilled labourers such as engaged in collecting empty plastic water bottles from the trains, rag picking, driving pedal rickshaw and loading unloading of goods. On the average they spent 8 hours a day on work to earn livelihood. Social, situational, and environmental factors are likely to be more influential in initial or lowlevel substance use, while individuals who progress from use to abuse or addiction are influenced to a greater extent by biological, psychological, and psychiatric factors. This distinction between risk factors is more thoroughly discussed in chapter. Protective factors are those characteristics that reduce the risk of substance abuse and addiction and promote positive development such as, appropriate role models, involvement in positive peer groups, and a positive self-image and outlook for the future. Social and Cultural Consequences of Adolescent Substance Abuse Drug abuse has led to a detrimental impact on the society. Apart from affecting the financial stability, addiction increases conflicts and causes untold emotional pain for every member of the family. With most drug users being in the formative age group, the loss in terms of human potential is incalculable. The damage to the physical, psychological, moral and intellectual growth of the youth is very high. Adolescent drug abuse is one of the major areas of concern in adolescent and young people s behavior. The use of substances may compromise an adolescent s mental and emotional development by interfering with how young people approach and experience interactions. 21 In addition, adolescents are at serious risk for a number of direct and indirect consequences, including the following: Traffic Accidents Nearly half (45%) of all deaths from traffic accidents are related to alcohol intoxication or influence of other drugs, and an estimated 18% of drivers age 16 to 20 (or 2.5 million adolescents) drive under the influence of alcohol. 22 School-Related Problems Adolescent substance abuse is associated with declining grades, absenteeism from school, and dropping out of school. Cognitive and behavioral problems experienced by teens abusing substances may interfere with their academic performance. 23 Risky Sexual Practices Adolescents who use drugs and alcohol are more likely than nonusing teens to have sex, initiate sex at a younger age, and have multiple sex partners, placing them at greater risk for unplanned pregnancies and HIV/ AIDS, hepatitis C, and other sexually transmitted diseases. 24 Delinquent Behavior Adolescents who use marijuana weekly are six times more likely than nonusers to report they run away from home, five times more likely to say they steal from places other than home, and four times more likely to report they physically attack people. 25 Juvenile Crime Adolescent drug use has led to increase in the crime rate. Addicts resort to crime to pay for their drugs. Drugs remove inhibition and impair judgment egging one on to commit offences. Incidence of eve- teasing, group clashes, assault and impulsive murders increase with drug abuse. Adolescents age 12 to 16 who have ever used marijuana are more likely at some point to have sold marijuana (24 percent vs. less than 1 percent), carried a handgun (21 percent vs. 7 percent), or been in a gang (14 percent vs. 2 percent) than youth who have never used marijuana. 26 Developmental Problems Substance abuse can compromise an adolescent s psychological and social development in areas such as the formation of a strong selfidentity, emotional and intellectual growth, establishment of a career, and the development of rewarding personal 170 Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society

5 relationships. 27 Physical and Mental Consequences Smoking marijuana can have negative effects on the user s mind and body. It can impair shor t-term memory and comprehension, alter one s sense of time, and reduce the ability to perform tasks that require concentration and coordination, such as driving a car. Evidence also suggests that the long-term effects of using marijuana may include increased risk of lung cancer and other chronic lung disorders, head and neck cancer, sterility 28, 18 in men, and infertility in women. Infections Increase in incidences of HIV, hepatitis B and C and tuberculosis due to addiction adds the reservoir of infection in the community burdening the health care system further. Women in India face greater problems fr om drug abuse. The consequences include domestic violence and infection with HIV, as well as the financial burden. Violence 87% of adolescent addicts being treated in a de-addiction center run by the Delhi police acknowledged being violent with family members. Most of the domestic violence is directed against women and occurs in the context of demands for money to buy drugs. At the national level, drug abuse is intrinsically linked with racketeering, conspiracy, corruption, illegal money transfers, terrorism and violence threatening the very stability of governments. Drug abuse and suicide have strong association. Future Use Disorders The earlier the age at which a person first drinks alcohol, the more likely that person is to develop an alcohol use disorder. A person who starts drinking alcohol at age 13 is four times more likely to develop alcohol dependence at some time in his or her life than someone who starts drinking at age Drug Trafficking and Legislation India has braced itself to face the menace of drug trafficking both at the national and international levels. Several measures involving innovative changes in enforcement, legal and judicial systems have been brought into effect. The introduction of death penalty for drugrelated offences has been a major deterrent. The Narcotic Drugs and Psychotropic Substances Act, 1985, were enacted with stringent provisions to curb this menace. The Act envisages a minimum term of 10 years imprisonment extendable to 20 years and fine of Rs. 1 lakh extendable up to Rs. 2 lakhs for the offenders. The Act has been further amended by making provisions for the forfeiture of properties derived from illicit drugs trafficking. Comprehensive strategy involving specific programmes to bring about an overall reduction in use of drugs has been evolved by the various government agencies and NGOs and is further supplemented by measures like education, counseling, treatment and rehabilitation programmes. India has bilateral agreements on drug trafficking with 13 countries, including Pakistan and Burma. Prior to 1999, extradition between India and the United States occurred under the auspices of a 1931 treaty signed by the United States and the United Kingdom, which was made applicable to India in However, a new extradition treaty between India and the United States entered into force in July A Mutual Legal Assistance Treaty was signed by India and the United States in October Signs and Symptoms of Substance Abuse People who interact with adolescents in the home or community need to be alert to changes in an adolescent s behavior and appearance that may signal substance abuse. By recognizing the potential warning signs and symptoms of substance use, you may be able to get help for a teenager in need of treatment. The following behavior changes, when extreme or lasting for more than a few days, may indicate alcohol-related or drug-related problems and the need for further screening by a professional. Sudden changes in personality without another known cause Loss of interest in once favorite hobbies, sports, or other activities Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 171

6 DELHI PSYCHIATRY JOURNAL Vol. 12 No.2 OCTOBER 2009 Sudden decline in performance or attendance at school or work Changes in friends and reluctance to talk about new friends Deterioration of personal grooming habits Difficulty in paying attention, forgetfulness Sudden aggressive behavior, irritability, nervousness, or giddiness Incr eased secretiveness, heightened sensitivity to inquiry Screening and Assessment of Adolescent Substance Abuse Screening for adolescent substance abuse should be conducted by health care delivery systems, juvenile justice and family court systems, and community organizations such as schools, vocational rehabilitation, and religious organizations. 30 Adolescents who should be screened for substance abuse include all teens who receive mental health assessments, enter the child welfare system, drop out of school, or stay at homeless shelters. Adolescents arrested or detained within the juvenile justice and family court systems also should be screened. 31 Screening for substance abuse should focus on the adolescent s severity of use and core associated factors such as mental health status, family history of parental addiction, functioning in school, and any legal problems. 32 Referral to a comprehensive assessment should be made for all adolescents whose screening reveals indicators (e.g., daily use of one or more substances) of serious substance abuse problems. 33 Treatment of Adolescent Substance Abuse Admissions to substance abuse treatment programs for persons age 17 or younger increased to 8.9 percent of all admissions in Persons age 19 and younger accounted for more than 49 percent of all admissions for marijuana use and dependence. 34 Among youth age 12 to 17, an estimated 175,000 have received tr eatment or counseling for their drug use, and 148,000 have received treatment or counseling for alcohol use. 35 A significant gap exists between the number of adolescents who need substance abuse treatment and those who receive it. According to a study in Minnesota, only one-fourth of youth age 14 to 17 who need substance abuse treatment received it. 36 Substance abuse treatment is effective for adolescents. A national study of community-based treatment programs for adolescents found that reported weekly marijuana use dropped by more than half in the year following treatment. Clients also reported less heavy drinking, less use of hard drugs, and less criminal involvement. Other benefits included better psychological adjustment and improved school performance after treatment. 37 Special Considerations for Adolescent Treatment Treating adolescents for substance abuse requires special consideration of the adolescent s individual experience and how it affects the nature and severity of his or her alcohol or drug use. Understanding the adolescent s situation will help explain why alcohol or drugs are used and how they became an integral part of his or her identity. Factors that need to be considered when tailoring treatment for adolescents include the following: Developmental Stages Treatment for adolescents must address their unique developmental needs, which vary with the age of the client. Developmental features of younger adolescents are different from those of older adolescents. For example, older adolescents are more capable of abstract thinking and are more likely to openly rebel than younger adolescents. 38 Ethnicity and Culture Norms, values, and health beliefs differ across cultures and can affect substance abuse treatment. For example, some cultural groups may consider treatment invasive; others may wish to involve the extended family. Treatment services need to be culturally 172 Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society

7 competent and use the preferred language of adolescent clients and their families. 39 Gender and Sexual Orientation Factors that influence adolescent substance abuse and involvement in treatment differ by gender. For example, whereas adolescent girls more often have internalizing coexisting disorders such as depression, boys are more likely to have externalizing disorders such as conduct disorders. Effective treatment for gay, bisexual, and transgendered youth includes helping them to acknowledge and accept their sexual identity. 40 Coexisting Mental Disorders Adolescents with substance abuse disorders are more likely than their abstinent peers to have coexisting mental health problems such as anxiety disorders, attention deficithyperactivity disorder, and depression. In these teens, substance abuse may disguise, exacerbate, or be used to self medicate psychiatric symptoms. Without tailored treatment, coexisting mental disorders could interfere with the adolescent s ability and motivation to participate in addiction treatment and could increase the potential 12, 25, 41 for relapse. Family Factors An adolescent s family has a potential role both in the origin of his or her substance abuse problem and as an agent of change in the adolescent s environment. Treatment should take into account family factors that increase risk for substance abuse problems in youth, such as any history of parental or sibling substance abuse problems or addiction; domestic violence; physical, sexual, or emotional abuse, and neglect. Whenever possible, parents should be involved in all phases of their adolescent s treatment. 42 Identification of Community Resources Your school district s nur sing staff, psychologist, social worker, or substance abuse coordinator or counselor may be able to identify local treatment programs. Other possible sources of referral information include your doctor, local hospital, pastor or clergy, and county mental health society. Public and private agencies, such as local health departments, state alcohol and drug authorities, and state and local professional societies may compile directories that can help you locate treatment programs. These directories may offer information on the types of facility settings and care provided as well as special services for adolescents. Ways to Support Adolescents in Treatment and Recovery Adolescents who are in treatment or recovery need all the support they can get from their families and communities. Consider taking one or more of the following actions to support youth undergoing treatment for and recovery from substance abuse. Encourage schools to offer student assistance programs, counseling on substance abuse, and confidential referral to treatment and recovery resources in the community. Encourage purchasers of health insurance to obtain comprehensive coverage for substance abuse and mental health services. Encourage treatment centers, schools, and community-based youth organizations to conduct support groups for children of parents who are addicted to alcohol and drugs. Encourage adolescents who have recovered successfully from addictive disorders to participate in community events that target their peers. Because alcohol and drug use among youth often occurs in groups, be aware that encouraging one young person to seek help may lead others in his or her social group to seek treatment. Encourage environmental changes in your community that promote recovery such as reducing the number of billboards advertising alcoholic beverages and holding alcohol-free recreational events. Encourage the participation of family members in all aspects of the treatment and recovery process for adolescents, and foster the availability of family-centered support groups and other services that address the needs of the entire family. Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 173

8 DELHI PSYCHIATRY JOURNAL Vol. 12 No.2 OCTOBER 2009 Be a positive role model for young people in treatment and recovery by not engaging in any illegal or unhealthy substance use. Get involved in organizations that advocate public policies and funding to support substance abuse treatment and recovery programs for adolescents. References 1. MacLeod A. Growing up in America A background to contemporar y drug use. Rockvikke Md: National Institute of Drug Abuse, American Academy of Pediatrics (AAP). Releases New Findings on Inhalant Abuse (Press Release), September 30, Lynch BS. and Bonnie RJ. Growing up tobacco free: Preventing nicotine addiction in children and youths. Washington, DC: National Academy Press Kastner Peter and Silber eisese RK. Drogengebrauch Jugendlicher auaentwicklungs psychologischer Sicht. In BildunUnd Erziehung, 1984; 37 : Conrad KM; Flay BR and Hill D. Why Children start smoking cigarettes: Predictors of onset. Br J Addiction 1992; 87 : Eiser JR, Morgan M, Gammage P and Gray E. Adolescent Smoking: Attitude, norms and parental influence. Br J Soc Psychol 1989; 28 : Aaro LE, Hauknes A, Berglund EL. Smoking among Norwegian school children : The Influence of Social Environment. Scand J Psychiat 1981; 22 : Elkind AK. The Social Definition of Women s Smoking Behaviour. Soc Sci Med 1985; 20 : Severson HH and Lichtenstein. Smoking Prevention Programmes for Adolescents: Rationale and Review. In: Krasnegor N and Cataldo M (Eds) Child Health and Behaviour, New York, Miley, Miller WJ and Hunter L. The Relationship between Socio-economic Status and Household Smoking Patterns in Canada. Am J Health Promotion 1990; 5 : Gritz ER. The Female Smokers: Research and Intervention Targets. In: JW Cullen and Lr Martin, (Eds), Psychological Aspects of Cancer. New York: Raven 1982; McGraw SA, Smith KW, Schensul JJ and Carrillo E. Socio-cultural Factors Associated with Smoking by Puerto Rican Adolescents in Boston. Soc Sci Med 1991; 33 : Ary DV and Biglan A. Longitudinal Changes in Adolescent Cigarette Smoking Behaviour and Cessation. J Behav Med 1988; 15(5) : Bandura A. Social Learning Theory, Eaglewood Cliffs, Prentice Hall, The Cigarette and Other Tobacco Products (production, advertisement, and regulation of trade and commerce, production supply and distribution) Act, Bjartveit K. Fifteen Years of Comprehensive Legislation: Results and Conclusions. Proceedings of 7th World Congress on Tobacco and Health. Perth Australia, Gaudette LA and Richardson A. Which Workers smoke? Health Reporter, 1994; 10(3) : UNICEF, Census Summary of Findings from the 1998 National Household Survey on Drug Abuse. DHHS Publication No. (SMA) Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Monitoring the Future Data from In- School Surveys of 8th, 10th, and 12th Graders. Table 1a: Trends in Lifetime Prevalence of Use of Various Drugs for 8th, 10th, and 12th Graders, Ann Arbor, MI: Survey Research Center, Institute for Social Research, University of Michigan, (Accessed December 20, 1999.) 22. Partnership for a Drug-Free America (PDFA) Partnership Attitude Tracking Study. New York, NY: PDFA, National Center on Addiction and Substance Abuse at Columbia University. Back to School National Survey of Amer ican Attitudes on Substance Abuse V: Teens and Their Parents. New York, NY: National Center on Addiction and Substance Abuse at Columbia University, Monitoring the Future Data from In- School Surveys of 8th, 10th, and 12th Graders. Table 10: Trends in Perceived Availability of 174 Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society

9 Drugs for 8th, 10th, and 12th Graders, Ann Arbor, MI: Survey Research Center, Institute for Social Research, University of Michigan, Center for Substance Abuse Treatment. The Science of Addiction: Simplified, Substance Abuse in Brief. Rockville, MD: Substance Abuse and Mental Health Services Administration, July Anthenelli RM, Schuckit MA. Genetic Studies of Alcoholism. Int J Addiction 1990; 25 : Merkiangas KR, Stolar M, Stevens DE, et al. Familial Transmission of Substance Use Disorders. Arch Gen Psychiatry 1998; 55 : National Institute on Drug Abuse (NIDA). Principles of Drug Addiction Treatment: A Research-Based Guide. NIH Publication No Rockville, MD: NIDA, National Institutes of Health, October Center for Substance Abuse Treatment. Treatment of Adolescents With Substance Abuse Problems. Treatment Improvement Protocol (T IP) Ser ies, No. 32. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Crowe AH. Drug Identification and Testing in the Juvenile Justice System: Summary. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice, National Center on Addiction and Substance Abuse at Columbia University. Dangerous Liaisons: Substance Abuse and Sex. New York, NY: National Center on Addiction and Substance Abuse at Columbia University, Greenblatt JC. Adolescent Self-Reported Behaviors and Their Association with Marijuana Use. In: Analyses of Substance Abuse and Treatment Need Issues. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 33. Synder HN, Sickmund M. Juvenile Offenders and Victims: 1999 National Report. Washington, DC: National Center for Juvenile Justice, Zhang ZF, Morgenstern H, Spitz MR, et al. Marijuana Use and Increased Risk of Squamous Cell Carcinoma of the Head and Neck. Cancer Epidemiology, Biomarkers, and Prevention 8(12) : , December Center for Substance Abuse Prevention. Tips for Teens About Marijuana. Rockville, MD: Substance Abuse and Mental Health Services Administration, Grant BF, Dawson DA. Age at Onset of Alcohol Use and its Association with DSM-IV Alcohol Abuse and Dependence. J Substance Abuse 1997; 9 : Center for Substance Abuse Treatment. Screening and Assessing Adolescents for Substance Use Disorders. Treatment Improvement Protocol (TIP) Series, No. 31. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. National Admissions to Substance Abuse Treatment Services: The Treatment Episode Data Set (TEDS) Rockville, MD: Substance Abuse and Mental Health Services Administration, Minnesota Department of Human Services. Estimate of the Need for Alcohol/Drug-Related Services for Adolescents in Minnesota: Implications for Managed Care Organizations and Health Care Providers. St. Paul, MN: Minnesota Department of Human Services, Performance Measur ement and Quality Improvement Division, Hser YI, Grella C, Hsieh SC, Anglin MD. National Evaluation of Drug Treatment for Adolescents. Presented at the College on Problems of Drug Dependence Annual Meeting, June Center for Substance Abuse Treatment. Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Use. Treatment Improvement Protocol (TIP) Series, No. 9. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Winters KC. Treating Adolescents with Substance Use Disorders: An Overview of Practice Issues and Treatment Outcome. Substance Abuse 1999; 20(4) : Delhi Psychiatry Journal 2009; 12:(2) Delhi Psychiatric Society 175

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